Coroner calls on police to review their use of capsicum spray

A Victorian Coroner has called for major changes to the way the state's emergency services respond to mentally ill people.

Coroner Jane Hendtlass's recommendations come two years after a lengthy inquest into the death of a man who was severely burnt when police sprayed him with capsicum spray during a tense stand-off in the state's far east.

James Bloomfield, 53, had doused himself with accelerant and was flicking a cigarette lighter when police sprayed him with capsicum spray at a Bairnsdale caravan park in November 2006.

He suffered burns to 90 per cent of his body and died the next day.

The coroner detailed Bloomfield's long and troubled build-up to the confrontation with police.

Five days earlier, a major power failure at the caravan park cut power to the caravan he called home.

The inquest heard Mr Bloomfield was terrified of the dark because it brought back childhood trauma, and he would sleep with the television on to light the caravan.

When the caravan went dark, Mr Bloomfield became extremely distressed.

Over the course of the next few days, he visited a number of agencies in Bairnsdale, asking for help to restore the light.

He became increasingly agitated and threatened to set himself on fire.

By the early hours of the 10th of November, Mr Bloomfield went to the emergency department of the local hospital, where he told staff "What do I have to do to get attention? Do I have to set fire to myself?"

He was given batteries for his torch.

Later that day he went to the Gippsland Lakes Community Health Centre, the Department of Human Services, and Community Housing Victoria, where he repeated his threats.

He also wrote down a list of phone numbers for the mental health centre to contact if he set himself on fire.

Finally, Mr Bloomfield was stopped by Bairnsdale police and taken to the emergency department of the local hospital, under section 10 of the Mental Health Act.

There was no psychiatrist, and the local community health service told the inquest it expected police to refer Mr Bloomfield's matter to a mental health triage nurse in Traralgon 120 kms away.

However, this did not happen.

Mr Bloomfield walked out of the hospital without receiving treatment but turned up again almost eight hours later, holding a petrol can.

Later, as he stood at the caravan park drenched in petrol and police tried to stop him with capsicum spray, the lighter in his hand sparked a fire that ignited the accelerant.

The inquest has drawn attention to what happens when someone vulnerable falls through the cracks left by emergency services trying to deal with mentally ill people in their care.

Coroner Hendtlass is so concerned about the issues raised by Mr Bloomfield's death, she has written to Victoria's Attorney General, Minister for Health, Minister for Mental Health and the Minister for Police and Emergency Services.

She has also contacted Victoria's Chief Psychiatrist, Ambulance Victoria and the Australian and New Zealand College of Emergency Medicine.

Among her recommendations are;

· That hospital emergency staff report to police all patients who arrived with police but go on to discharge themselves;

· That Victoria Police and Ambulance Victoria establish a new code for transporting patients suspected to have a mental illness;

· And that a new commission or agency be established to better cope with mentally ill people across the justice and health systems;

Coroner Hendtlass is also calling on Victoria Police to better train its members on the flammable nature of capsicum spray.

She also wants an independent review of the spray to try to find a non-flammable alternative.

A senior weapons expert at Victoria Police told the inquest two years ago that he recommended a water-based replacement.